Provider Demographics
NPI:1194861955
Name:SMOKE, ROGER L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:L
Last Name:SMOKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 W END AVE APT 93
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3542
Mailing Address - Country:US
Mailing Address - Phone:212-749-7953
Mailing Address - Fax:212-961-9078
Practice Address - Street 1:924 W END AVE APT 93
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3542
Practice Address - Country:US
Practice Address - Phone:212-749-7953
Practice Address - Fax:212-961-9078
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112967207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00204715Medicaid
NY00204715Medicaid